Or. Admin. Code § 410-141-3510 - Provider Contracting and Credentialing
(1) Managed Care Entity's (MCEs) shall
develop policies and procedures for credentialing providers to include quality
standards and a process to remove providers from their provider network if they
fail to meet the objective quality standards.
(a) MCEs shall ensure that all participating
providers as defined in OAR
410-141-3500 providing
coordinated care services to members are credentialed upon initial contract
with the MCE and re-credentialed no less frequently than every three (3) years.
The credentialing and re-credentialing process shall include review of any
information in the National Practitioners Databank. MCEs shall accept both the
Oregon Practitioner Credentialing Application and the Oregon Practitioner
Recredentialing Application;
(b)
MCEs shall screen their participating providers to be in compliance with 42 CFR
455 Subpart E (42 CFR
455.410 through
42 CFR
455.470) and retain all resulting
documentation for audit purposes, except in the following circumstances for
credentialing COVID-19 vaccine administration providers for the sole purpose of
administering COVID-19 vaccines or the administration of the flu vaccine when
administered in conjunction with the COVID-19 vaccination. For the purpose of
this rule, COVID-19 vaccination administration provider means a healthcare
provider that has successfully enrolled with the Authority's Public Health
Division to be a COVID-19 vaccination administration provider, completed all
required training, and has agreed to all terms of program participation.
(A) MCEs may rely upon the most recent weekly
update of the Authority's active file of vaccine administration providers to
meet contractual and regulatory requirements for credentialing COVID-19 vaccine
administration providers.
(B) MCEs
may enroll COVID-19 vaccine administration providers who are included in the
Authority's most recent active file of vaccine administration
providers.
(C) MCEs shall monitor
changes in the Authority's weekly active file of vaccine administration
providers for terminations and changes.
(c) MCEs shall screen their contracted HRSN
Service Providers to be in compliance with
42 CFR §§
455.410 through
455.436,
455.450,
455.452, and
455.470, and retain all resulting
documentation for audit purposes.
(d) MCEs may elect to contract for or
delegate responsibility for the credentialing and screening processes; however,
MCEs shall be solely and ultimately responsible for adhering with all terms and
conditions held in its contract with the state. For the following activities
including oversight of the following processes regardless of whether the
activities are provided directly, contracted, or delegated, MCEs shall:
(A) Ensure that coordinated care services are
provided within the scope of license or certification of the participating
provider or facility and within the scope of the participating provider's
contracted services. They shall ensure participating providers are
appropriately supervised according to their scope of practice;
(B) Provide training for MCE staff and
participating providers and their staff regarding the delivery of coordinated
care services, applicable administrative rules, and the MCEs administrative
policies.
(e) The MCE
shall provide accurate and timely information to the Authority about:
(A) License or certification expiration and
renewal dates;
(B) Whether a
provider's license or certification is expired or not renewed or is subject to
licensing termination, suspension, or certification sanction;
(C) If an MCE knows or has reason to know
that a provider has been convicted of a felony or misdemeanor related to a
crime or violation of federal or state laws under Medicare, Medicaid, or Title
XIX (including a plea of "nolo contendere");
(D) If an MCE removes a provider or fails to
renew a provider's contract if the provider fails to meet objective quality
standards.
(f) MCEs may
not refer members to or use providers that:
(A) Have been terminated from
Medicaid;
(B) Have been excluded as
a Medicaid provider by another state;
(C) Have been excluded as Medicare/Medicaid
providers by CMS; or
(D) Are
subject to exclusion for any lawful conviction by a court for which the
provider may be excluded under
42 CFR
1001.101.
(g) MCEs may not accept billings for services
to members provided after the date of the provider's exclusion, conviction, or
termination. MCEs shall recoup any monies paid for services to members provided
after the date of the provider's exclusion, conviction, or
termination;
(h) MCEs shall require
each atypical provider to be enrolled with the Authority. MCEs shall also
require each atypical provider, except HRSN Service Providers, unless that HRSN
Service Provider is a licensed and credentialed professional authorized to bill
Medicaid, to obtain and use registered National Provider Identifiers (NPIs),
and taxonomy codes reported to the Authority in the Provider Capacity Report
for purposes of encounter data submission prior to submitting encounter data in
connection with services by the provider. MCEs shall require each qualified
provider, except HRSN Service Providers, to have and use an NPI as enumerated
by the National Plan and Provider Enumeration System (NPPES);
(i) The provider enrollment request (for
encounter purposes) and credentialing documents require the disclosure of
taxpayer identification numbers. The Authority shall use taxpayer
identification numbers for the administration of this program including
provider enrollment, internal verification, and administrative purposes for the
medical assistance program for administration of tax laws. The Authority may
use taxpayer identification numbers to confirm whether the individual or entity
is subject to exclusion from participation in the medical assistance program.
Taxpayer identification number includes Employer Identification Number (EIN),
Social Security Number (SSN), and Individual Tax Identification Number (ITIN)
used to identify the individual or entity on the enrollment request form or
disclosure statement. Disclosure of all tax identification numbers for these
purposes is mandatory. Failure to submit the requested taxpayer identification
numbers may result in denial of enrollment as a provider and denial of a
provider number for encounter purposes or denial of continued enrollment as a
provider and deactivation of all provider numbers used by the provider for
encounters.
(2) An MCE
may not discriminate with respect to participation in the MCE against any
health care provider who is acting within the scope of the provider's license
or certification under applicable state law on the basis of that license or
certification. If an MCE declines to include individual or groups of providers
in its network, it shall give the affected providers written notice of the
reason for its decision. This rule may not be construed to:
(a) Require that an MCE contract with any
health care provider willing to abide by the terms and conditions for
participation established by the MCE; or
(b) Preclude the MCE from establishing
varying reimbursement rates based on quality or performance measures. For
purposes of this section, quality and performance measures include all factors
that advance the goals of health system transformation including:
(A) Factors designed to maintain quality of
services and control costs and are consistent with its responsibilities to
members; or
(B) Factors that add
value to the service provided including but not limited to expertise,
experience, accessibility, or cultural competence.
(c) The requirements in subsection (2)(b) of
this rule do not apply to reimbursement rate variations between providers with
the same license or certification or between specialists and non-specialty
providers.
(3) An MCE
shall establish an internal review process for a provider aggrieved by a
decision under section (2) of this rule including an alternative dispute
resolution or peer review process. An aggrieved provider may appeal the
determination of the internal review to the Authority.
(4) To resolve appeals made to the Authority
under sections (2) and (3) of this rule, the Authority shall provide
administrative review of the provider's appeal using the administrative review
process established in OAR
410-120-1580. The Authority
shall invite the aggrieved provider and the MCE to participate in the
administrative review. In making a determination of whether there has been
discrimination, the Authority shall consider the MCE's:
(a) Network adequacy;
(b) Provider types and
qualifications;
(c) Provider
disciplines; and
(d) Provider
reimbursement rates.
(5)
A prevailing party in an appeal under sections (3) through (4) of this rule
shall be awarded the costs of the appeal.
(6) MCEs shall not apply any requirement that
any entity operated by the IHS, an Indian tribe, tribal organization or urban
Indian organization be licensed or recognized under the State or local law
where the entity is located to furnish health care services, if the entity
meets all the applicable standards for such licensure or recognition. This
requirement is pursuant to 25 USC 1621t and
1647a.
(7) MCEs shall not require the licensure of a
health professional employed by such an entity under the State or local law
where the entity is located, if the professional is licensed in another
State.
(8) MCEs shall offer
contracts to all Medicaid eligible IHCPs and to provide timely access to
specialty and primary care within their networks to MCE enrolled IHS
beneficiaries seen and referred by IHCPs, regardless of the IHCPs status as
contracted provider within the MCE network.
(9) MCEs shall ensure that all contracted
HRSN Service Providers meet the specific provider qualifications to provide
HRSN Services to HRSN Authorized Members as described in
OAR-410-120-2030.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065, 414.572, 414.665, 414.719, 414.632 & 414.605
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